Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 7, Number 5—October 2001
Research

Clinical Consequences and Cost of Limiting Use of Vancomycin for Perioperative Prophylaxis: Example of Coronary Artery Bypass Surgery

Giorgio Zanetti*†Comments to Author , Sue J. Goldie‡, and Richard Platt*§
Author affiliations: *Channing Laboratory, Brigham and Women's Hospital, and Eastern Massachusetts CDC Prevention Epicenter, Boston, Massachusetts, USA; †University Hospital, Lausanne, Switzerland; ‡Harvard School of Public Health, Boston, Massachusetts, USA; §Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA

Main Article

Table 1

Model variablesa

Variables Base case Plausible range References
Incidence of SSI
  Superficial 0.08 0.02 – 0.12 (12,17)
  Deep 0.04 0.01 – 0.06 (12,17)
Causative organisms: (12,13)
  Staphylococcus aureus 0.25 0.20 – 0.35
  Coagulase-negative Staphylococci 0.25 0.20 - 0.35
  Enterococci 0.05 0.02 - 0.15
  Gram-negative bacteria 0.30 0.15 – 0.50
Relative risk of SSI caused by susceptible organisms
  Vancomycin vs. no prophylaxis 0.4 0.20 – 0.80 (18-23)
  Cefazolin vs. no prophylaxis 0.4 0.20 – 0.80 (18-23)
Incidence of antibiotic-related adverse events
  Vancomycin 0.08 0.01 – 0.20 (24)
  Cefazolin 0.08 0.01 – 0.20 (24,25)
Incidence of SSI due to resistant organisms (26)
  MRSA (% of all SSI due to S. aureus) 0.012 0 – 0.03
(0.40)
  Methicillin-resistant CNS (% of all 0.024 0 – 0.03
  SSI due to CNS) (0.80)
  VRE (% of all SSI due to enterococci) 0.003 0 - 0.006
(0.15)
  Incidence of SSI caused by cefazolin-susceptible Gram-negative bacteria (% of all SSI due to gram-negative bacteria) 0.01 (0.28) 0 – 0.036
History of allergy to beta-lactams 0.1 0.05 – 0.15 (27)
Probability of hospital death
  Deep surgical site infection 0.082 0.01 – 0.10 (12)
  Antibiotic allergic reaction 0.00002 (28)
  Coronary artery bypass graft surgery-related events 0.036 0.01 – 0.1 (29)
Costs per case (US$)
  Vancomycin 80 60 – 250 (24)
  Cefazolin 24 10 – 50 (24)
  Superficial SSI 8,000 3000 – 15,000 (30,31)
  Deep SSI 36,800 10,000 – 50,000 (30,31)
  Vancomycin-related adverse event 107 20 – 1,000 (24)
  Cefazolin-related adverse event 107 20 – 1,000 (24)
  Death 5,900 0 – 10,000 (32)
  Multiplication factor for infections due to methicillin-resistant organisms
 1.13
 0.9 - 2
 (33)
  Multiplication factor for infections due to VRE 1.5 0.9 - 3 b

aSSI = surgical site infection; MRSA = methicillin-resistant Staphylococcus aureus; CNS = coagulase-negative staphylococci; VRE: vancomycin-resistant enterococci.
bWe assumed that the cost of an infection caused by a vancomycin-resistant enterococcus was 50% greater than the cost of a comparable infection caused by a susceptible strain.

Main Article

References
  1. Waldvogel  FA. New resistance in Staphylococcus aureus. N Engl J Med. 1999;340:556–7. DOIPubMedGoogle Scholar
  2. Smith  TA, Pearson  ML, Wilcox  KR, Cruz  C, Lancaster  MV, Robinson-Dunn  B, Emergence of vancomycin resistance in Staphylococcus aureus. N Engl J Med. 1999;340:493–501. DOIPubMedGoogle Scholar
  3. Jarvis  WR. Epidemiology, appropriateness, and cost of vancomycin use. Clin Infect Dis. 1998;26:1200–3. DOIPubMedGoogle Scholar
  4. Martone  WJ. Spread of vancomycin-resistant enterococci: why did it happen in the United States? Infect Control Hosp Epidemiol. 1998;19:539–45. DOIPubMedGoogle Scholar
  5. Centers for Diseases Control and Prevention. Recommendations for preventing the spread of vancomycin resistance. Recommendations of the Hospital Infection Control Practices Advisory Committee. MMWR Morb Mortal Wkly Rep. 1995;44:1–13.PubMedGoogle Scholar
  6. Woods  RK, Dellinger  EP. Current guidelines for antibiotic prophylaxis of surgical wounds. Am Fam Physician. 1998;57:2731–40.PubMedGoogle Scholar
  7. Dellinger  EP, Gross  PA, Barrett  TL, Krause  PJ, Martone  WJ, McGowan  JE Jr, Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis. 1994;18:422–7. DOIPubMedGoogle Scholar
  8. Page  CP, Bohnen  JM, Fletcher  JR, McManus  AT, Solomkin  JS, Wittmann  DH. Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care. Arch Surg. 1993;128:79–88. DOIPubMedGoogle Scholar
  9. Kaiser  AB. Antimicrobial prophylaxis in surgery. N Engl J Med. 1986;315:1129–38. DOIPubMedGoogle Scholar
  10. ASHP Commission on Therapeutics. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Clin Pharm. 1992;11:483–513.PubMedGoogle Scholar
  11. Martin  C. the French Study Group on Antimicrobial Prophylaxis in Surgery, The French Society of Anesthesia and Intensive Care. Antimicrobial prophylaxis in surgery: general concepts and clinical guidelines. Infect Control Hosp Epidemiol. 1994;15:463–71. DOIPubMedGoogle Scholar
  12. L'Ecuyer  PB, Murphy  D, Little  JR, Fraser  VJ. The epidemiology of chest and leg wound infections following cardiothoracic surgery. Clin Infect Dis. 1996;22:424–9. DOIPubMedGoogle Scholar
  13. Mossad  SB, Serkey  JM, Longworth  DL, Cosgrove  DM, Gordon  SM. Coagulase-negative staphylococcal sternal wound infections after open heart operations. Ann Thorac Surg. 1997;63:395–401. DOIPubMedGoogle Scholar
  14. Gold  MR, Siegel  JE, Russell  LB, Weinstein  MC, eds. Cost-effectiveness in health and medicine. New York: Oxford; 1996.
  15. Kim  C, Kwok  YS, Saha  S, Redberg  RF. Diagnosis of suspected coronary artery disease in women: a cost-effectiveness analysis. Am Heart J. 1999;137:1019–27. DOIPubMedGoogle Scholar
  16. Peduzzi  P, Kamina  A, Detre  K. Twenty-two year follow-up in the VA cooperative study of coronary artery bypass surgery for stable angina. Am J Cardiol. 1998;81:1393–9. DOIPubMedGoogle Scholar
  17. Sands  K, Yokoe  D, Hooper  D, Tully  J, Platt  R. A multi-institutional comparison of surgical site infection surveillance by screening of administrative and pharmacy data. Proceedings of the 8th Annual Meeting of the Society for Healthcare Epidemiology of America, San Francisco, CA, 1999. Thorofare (NJ):Slack Inc; 2000. Abstract M35.
  18. Platt  R, Zaleznik  DF, Hopkins  CC, Dellinger  EP, Karchmer  AW, Bryan  CS, Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med. 1990;322:153–60. DOIPubMedGoogle Scholar
  19. Kaiser  AB, Clayson  KR, Mulherin  JL, Roach  AC, Allen  TR, Edwards  WH, Antibiotic prophylaxis in vascular surgery. Ann Surg. 1978;188:283–189. DOIPubMedGoogle Scholar
  20. Platt  R, Zucker  JR, Zaleznick  DF, Hopkins  CC, Dellinger  EP, Karchmer  AW, Prophylaxis against wound infection following herniorrhaphy or breast surgery. J Infect Dis. 1992;166:556–60. DOIPubMedGoogle Scholar
  21. Bold  RJ, Mansfield  PF, Berger  DH, Pollock  RE, Singletary  SE, Ames  FC, Prospective, randomized, double-blind study of prophylactic antibiotics in axillary lymph node dissection. Am J Surg. 1998;176:239–43. DOIPubMedGoogle Scholar
  22. Platt  R, Zucker  JR, Zaleznick  DF, Hopkins  CC, Dellinger  EP, Karchmer  AW, Perioperative antibiotic prophylaxis and wound infection following breast surgery. J Antimicrob Chemother 1993;31 Suppl B:43-8.
  23. Bencini  PL, Galimberti  M, Signorini  M, Crosti  C. Antibiotic prophylaxis of wound infections in skin surgery. Arch Dermatol. 1991;127:1357–60. DOIPubMedGoogle Scholar
  24. Garrelts  JC, Horst  WD, Silkey  B, Gagnon  S. A pharmacoeconomic model to evaluate antibiotic costs. Pharmacotherapy. 1994;14:438–45.PubMedGoogle Scholar
  25. Maki  DG, Bohn  MJ, Stolz  SM, Kroncke  GM, Acher  CW, Myerowitz  PD. Comparative study of cefazolin, cefamandole, and vancomycin for surgical prophylaxis in cardiac and vascular operations. J Thorac Cardiovasc Surg. 1992;104:1423–34.PubMedGoogle Scholar
  26. Centers for Disease Control and Prevention. National Nosocomial Infection Surveillance System. NNIS antimicrobial resistance surveillance report. 1999. Available from: URL: http://www.cdc.gov/ncidod/hip/NNIS/AR_Surv1198.htm
  27. Condemi  JJ, Sheehan  MG. Allergy to penicillin and other antibiotics. In: Reese RE, Betts RF, editors. A practical approach to infectious diseases. 4th ed. Boston: Little, Brown and Co.; 1996. p. 1037-58.
  28. Idsol  O. Nature and extent of penicillin side reactions with particular reference to fatalities from anaphylactic shock. Bull World Health Organ. 1968;38:159.PubMedGoogle Scholar
  29. Ghali  WA, Ash  AS, Hall  RE, Moskowitz  MA. Statewide quality improvement initiatives and mortality after cardiac surgery. JAMA. 1997;277:379–82. DOIPubMedGoogle Scholar
  30. VandenBergh  MFQ, Kluytmans  JAJW, van Hout  BA, Maat  APWN, Seerden  RJ, McDonnel  J, Cost-effectiveness of perioperative mupirocin nasal ointment in cardiothoracic surgery. Infect Control Hosp Epidemiol. 1996;17:786–92. DOIPubMedGoogle Scholar
  31. Zoutman  D, McDonald  S, Vethanayagan  D. Total and attributable costs of surgical-wound infections at a canadian tertiary-care center. Infect Control Hosp Epidemiol. 1998;19:254–9. DOIPubMedGoogle Scholar
  32. Hall  RE, Ash  AS, Ghali  WA, Moskowitz  MA. Hospital cost of complications associated with coronary artery bypass graft surgery. Am J Cardiol. 1997;79:1680–2. DOIPubMedGoogle Scholar
  33. Rubin  RJ, Harrington  CA, Poon  A, Dietrich  K, Greene  JA, Moiduddin  A. The economic impact of Staphylococcus aureus infection in New York City hospitals. Emerg Infect Dis. 1999;5:1–12. DOIPubMedGoogle Scholar
  34. Penketh  AR, Wansbrough-Jones  MH, Wright  E, Pepper  JR, Parker  DJ. Antibiotic prophylaxis for coronary artery bypass graft surgery. Lancet. 1985;1:1500. DOIPubMedGoogle Scholar
  35. Fong  IW, Baker  CB, McKee  DC. The value of prophylactic antibiotics in aorto-coronary bypass operations: a double-blind randomized trial. J Thorac Cardiovasc Surg. 1979;78:908–13.PubMedGoogle Scholar
  36. Suter  F, Avai  A, Gerundini  M, Caprioli  S, Maggiolo  F. Teicoplanin versus cefamandole in the prevention of infection in total hip replacement. Eur J Clin Microbiol Infect Dis. 1994;13:793–6. DOIPubMedGoogle Scholar
  37. Vuorisalo  S, Pokela  R, Syrjälä  H. Comparison of vancomycin and cefuroxime for infection prophylaxis in coronary artery bypass surgery. Infect Control Hosp Epidemiol. 1998;19:234–9. DOIPubMedGoogle Scholar
  38. Fryback  DG, Dasbach  EJ, Klein  R, Klein  BEK, Dorn  N, Peterson  K, The Beaver Dam health outcomes study: initial catalog of health-state quality factors. Med Decis Making. 1993;13:89–102. DOIPubMedGoogle Scholar
  39. Bureau of Labor Statistics. Consumer price indexes. 1999. Available from: URL: http://stats.bls.gov/cpihome.htm
  40. Hlatky  MA, Rogers  WJ, Johnstone  I, Boothroyd  D, Brooks  MM, Pitt  B, Medical care costs and quality of life after randomization to coronary angioplasty or coronary bypass surgery. N Engl J Med. 1997;336:92–9. DOIPubMedGoogle Scholar
  41. Coast  J, Smith  RD, Millar  MR. An economic perspective on policy to reduce antimicrobial resistance. Soc Sci Med. 1998;46:29–38. DOIPubMedGoogle Scholar
  42. The National Academies, Institute of Medicine. To err is human: building a safer health system. 1999. Available from: URL: http://www4.nationalacademies.org/news.nsf
  43. Lawrence  L, Hall  MJ. National Center for Health Statistics. 1977 summary: national hospital survey. Adv Data. 1999;308:1–16.PubMedGoogle Scholar

Main Article

Page created: April 26, 2012
Page updated: April 26, 2012
Page reviewed: April 26, 2012
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
file_external